Vitamin C Fortification of Food Aid Commodities: Final Report (1997)

The United States contributes a variety of food commodities to global food aid through the Food for Peace Program authorized by Public Law (P.L.) 480, Title II. These commodities include cereal grains (corn, wheat, rice, sorghum), pulses (peas, beans, lentils), and a variety of milled cereal and blended products (e.g., wheat flour, bulgur, cornmeal, soy flour, soy flour-cornmeal blend). These commodities are procured for the U.S. Agency for International Development (USAID) by the U.S. Department of Agriculture (USDA)/Export Operations Division/Farm Service Agency. The Commodity Credit Corporation of USDA develops specifications and issues invitations to bid on supplying commodities for the export program. The commodities are produced by commercial companies in the United States under inspection by the USDA Federal Grain Inspection Service. P.L. 480 imposes a variety of restrictions: for example, all ingredients must have been produced and mixed in the United States, and the supplier must deliver the commodity dockside for ship transport. In 1996, approximately 1.7 million metric tons of food aid commodities valued at more than $840 million were distributed through Title II programs (USAID, 1996).

Two blended, fortified commodities are produced for distribution in the Food for Peace Program: corn-soy blend (CSB) and wheat-soy blend (WSB). These blended foods are a mixture of the appropriate cereal (gelatinized cornmeal or wheat flour and wheat protein concentrate), defatted soy flour, and soybean oil; they are fortified with 6 essential minerals and 11 vitamins (Table 1-1). The blended product has a higher protein (20 percent for WSB, 16–17 percent for CSB) and energy content (360 kcal/100 g for WSB, 380 kcal/100 g for CSB) than unblended cereal commodities as well as higher levels of vitamins and minerals due to fortification (Tables 1-2 and 1-3).

These highly fortified blended foods are provided as ration supplements to refugees and displaced persons in camps and to beneficiaries of developmental aid programs that are targeted largely to mothers and children. (Developmental aid uses food primarily in school feeding programs, in maternal and child health programs, and in food-for-work projects where the food is used as a substitute for money to pay for labor on development projects. Developmental food aid is rarely the sole source of food for the family.) These blended, cereal-based foods are partially precooked during processing, which allows them to be incorporated easily into a number of different food preparations that are acceptable to many different cultures and to be prepared by the recipient with a minimal use of fuel.

It has been estimated that 44 percent of global food aid deliveries were financed by the United States in 1996. However, the United States supplied 84 percent of the total blended, fortified foods used worldwide (Dr. Judit Katona-Apte, World Food Programme, United Nations, personal communication, 1997). Of the blended, fortified food commodities provided by the United States in

majority of this (75 percent) going to India for development feeding programs. Only 18 percent of U.S.-supplied CSB and WSB went to Africa (USAID, 1997 a, b).

Beginning in fiscal year (FY) 1993, U.S. congressional appropriations committees urged USAID to increase the amount of vitamin C (L-ascorbic acid) added to blended commodities exported through the P.L. 480 Title II Food for Peace program to levels more than twice those currently in use (Foreign Operations, Export Financing, and Related Programs Appropriations Bill, 1993, S. Rpt. 102–419, 1994, S. Rpt. 103–142) (see Appendix A). The commodities targeted for increased fortification with vitamin C were CSB and WSB—the only commodities exported in the Food for Peace program that are fortified with vitamin C. The stated purpose of the increased vitamin C fortification of these blended foods was to improve the health of food aid recipients and reduce the need for, and cost of, later medical interventions (Foreign Operations, Export Financing, and Related Programs Appropriations Bill, 1994, S. Rpt. 103–142). The 1995 congressional report asked for information on the cost of the increased fortification and the stability of vitamin C throughout the shipping process (Making Appropriations for the Foreign Operations, Export Financing, and Related Programs for the fiscal year ending September 30, 1995, Conference Report, H. Rpt. 103–633, 1995).

In response to the original 1993 congressional appropriations bill language, USAID's Bureau for Humanitarian Response (BHR) commissioned an examination of the various options for appropriate micronutrient fortification of USAID food aid commodities. The resulting technical review paper Micronutrient Fortification and Enrichment of P.L. 480 Title II Commodities: Recommendations for Improvement (OMNI, 1994) addressed fortification with many nutrients, including vitamin C, and provided cost information. That report, as well as Toole (1994), documented that the most widespread micronutrient deficiencies are iron deficiency anemia, which occurs worldwide, and vitamin A deficiency, which is endemic in South Asia and in eastern and southern Africa. Iodine deficiency also exists in most regions of the world, whereas deficiencies of vitamin C, niacin, and thiamin tend to be infrequent and very localized. The 1994 OMNI (Opportunities for Micronutrient Intervention) report recommended that vitamin C fortification levels be maintained at 40 mg/100 g until further information became available on the stability of vitamin C during storage and preparation. In response, Hoffmann La-Roche, Inc. (a vitamin manufacturer), submitted comments on the recommendations, including the following, ''Of particular concern is the inconsistency of supplementation levels and the inadequacy of the vitamin C supplementation in exported grains.''¹ USAID was

able to obtain some analyses of the vitamin C content of blended foods,² but information was lacking on how much vitamin C actually reaches the recipient at the time of food preparation and consumption.

The stability of vitamin C (L-ascorbic acid) is of concern because this is one of the most labile vitamins in foods. Its main loss during processing and storage is from oxidation, which is accelerated by light, oxygen, heat, increased pH, high moisture content (water activity), and the presence of copper or ferrous salts. To reduce oxidation, the vitamin C used in commodity fortification is coated with ethyl cellulose (2.5 percent). Oxidative losses also occur during food processing and preparation, and additional vitamin C may be lost if it dissolves into cooking liquid and is then discarded.

The FY 1996 Senate Appropriations Committee Report 104–143, "Foreign Operations, Export Financing, and Related Programs Appropriation Bill, 1996," directed USAID to initiate a pilot program to increase the vitamin C content of CSB and WSB to 90 mg per 100 g and to report on the results (Appendix A). In response, USAID set up a cooperative agreement with the organization SUSTAIN (Sharing United States Technology to Aid in the Improvement of Nutrition) to devise and implement the pilot program. USAID also asked the Institute of Medicine to form a committee to address the cost-effectiveness and advisability of increasing the level of vitamin C used to fortify the food aid commodities CSB and WSB. The Committee on International Nutrition—Vitamin C in Food Aid Commodities was constituted in response to this request.

The committee's overall task was to address the cost-effectiveness and advisability of scaling up vitamin C fortification of the Title II commodities CSB and WSB to improve recipients' diet, nutrition, and health. First, the committee was to review the proposed pilot program, examining it for soundness of scientific and technical design in relation to (1) monitoring the presence and stability of vitamin C in food aid commodities and (2) assessing the dietary intake of vitamin C, nutritional status, and health status of recipients. Based on this review, the committee was to prepare a brief report to recommend modifications needed to improve the pilot program's design.

For this final report, the committee's specific role was to assess the results of the pilot program; estimate the need for increased vitamin C fortification to improve recipient diet, nutrition, and health; and estimate the cost-effectiveness of increased fortification with vitamin C. In addition, this report provides recommendations regarding both the advisability of scaling up Title II

commodity fortification with vitamin C and the appropriateness of this approach compared with other means of delivering vitamin C.

The committee met twice during the study. Prior to and during the first meeting, committee members reviewed The Vitamin C Pilot Program (Ranum and Chomé, 1996), excerpts from the report Micronutrient Fortification and Enrichment of P.L. 480 Title II Commodities: Recommendations for Improvement, Technical Review Paper (OMNI, 1994), and a variety of other materials. An open session with representatives of USAID and SUSTAIN, USDA, the Food and Drug Administration, Kellogg Corporation, and Protein Grain Products International was also held. The committee then deliberated in executive session and prepared its report Vitamin C in Food Aid Commodities: Initial Review of a Pilot Program (IOM, 1996). In particular, the report reviewed the plan for the pilot program designed by SUSTAIN, presented recommendations for its improvement, and identified additional information needed to complete the overall task. The committee emphasized the potential value of collecting data from emergency feeding programs, as well as from development programs, and of collecting samples on-site to determine vitamin C losses during food preparation. It also stressed the need for cost data and information on both the prevalence of scurvy and insufficient vitamin C and iron intakes in populations that receive blended foods. SUSTAIN had access to the committee's initial report as it completed its pilot program.

The committee staff, under committee guidance, conducted an extensive literature search to attain a more global view of the reported incidence of scurvy in refugee populations, the effects of vitamin C on iron absorption, and other potential health effects of increased vitamin C supplementation. The committee also contacted the United Nations World Food Programme (WFP) for additional information on the vitamin C status of food aid recipients.

Prior to and during its second meeting, the committee reviewed SUSTAIN's report Results Report on the Vitamin C Pilot Program (Ranum and Chomé, 1997) and assessed needs for additional information. An open session was held by videoconference with representatives of USAID and SUSTAIN. Information on the tonnage of CSB and WSB produced and their distribution in development versus emergency relief programs was obtained, along with information on costs of the various methods of providing vitamin C. The committee teleconferenced with a UN representative for additional insights into global food aid needs.

This range of activities provided the committee with the information on which it based its deliberations. This report presents the results of the committee's analyses and deliberations, as well as its conclusions and recommendations. This chapter provides the background for the study and the

committee's charge. Chapter 2 focuses on the prevalence of scurvy, vitamin C requirements, and the role of vitamin C in other aspects of human health. Chapter 3 presents cost-effectiveness analysis of vitamin C fortification. Chapter 4 summarizes pilot program results, and Chapter 5 contains the committee's critique of the pilot program. The committee's conclusions and recommendations are presented in Chapter 6.